Comments have flowed in from around the world in response to an essay in the New England Journal of Medicine about clinicians' emotions when they are faced with a patient's death. From Greater Boston have come notes on saying goodbye before death, staying engaged at the worst times, coping with suicide, crying and celebrating with patients, and turning the tables when the doctor's time comes.

Doctors, nurses, students and others offered their thoughts in an online forum on Dr. Katharine Treadway's
"The Code." She wrote that after a patient's death, she says aloud this phrase from a requiem mass: "May choirs of angels greet thee at thy coming."

Dr. Naomi Leeds of Massachusetts General Hospital commented that she wrote a letter to a patient dying of esophageal cancer to tell him how he had touched her life.

"I welcomed the opportunity for closure and was grateful that my colleague encouraged me to do this — I would not have thought to do this on my own," she wrote. "I think that we would all benefit by having more training on how to say goodbye and thank you to our patients who we know are going to die."

Dr. Robert Truog of Children's Hospital Boston said the essay gave him a chance to reflect on why he chose to specialize in pediatric intensive care medicine. Initially drawn to the challenge and excitement of making life and death decisions on a moment's notice, he has changed.

"In the long run, however, what has kept me most engaged in my specialty has been the opportunity to work with children and their parents through the worst times of their lives, helping them make decisions when none of the choices are good, and comforting them through the unimaginable depths of loss and sadness that accompany the death of a child," he wrote.

Death is "often uncommon and often traumatic for all involved" in child psychiatry, Dr. Steve Auster of Wellesley wrote. After a patient's suicide, clinicians met to talk about it and some of them attended the wake.

"Hard to imagine all that being possible in disciplines where death is more common, however that doesn't lessen the potential benefit of this processing," he wrote.

Stephanie Gill, a family nurse practitioner in Norwood, tries to put herself in the shoes of her patients.

"I've cried with them when it's bad news and celebrated with them when it's good news," she wrote. "I think the fact that we can make such a difference in someone's life (and in their death) is amazing."

And Dr. Thomas Amoroso of Quincy Medical Center said that spiritual rituals make him uncomfortable.

"To be honest, at my passing I want someone to make either a good joke, or best of all, a really bad pun," he wrote. "Honoring someone's life takes many forms, and I feel it is important to acknowledge that as well."

Drug giant Novartis AG says it will give its Cambridge neighbor, MIT, $65 million over 10 years to create a research program, likely to be the biggest in the world aimed at revolutionizing the way drugs are made.

The Food and Drug Administration does very little to ensure the safety of the millions of people who participate in clinical trials, a federal investigator has found.

The Food and Drug Administration yesterday gained broad new powers to ensure the safety of prescription drugs used by millions of Americans under a bill signed by President Bush.

After a lengthy career at Harvard Medical School as a researcher and professor of biological chemistry and molecular pharmacology, Dr. Roger W.Jeanloz (left) became a tutor with the Faculty of Arts and Sciences, retiring in June. He died of pneumonia Sept. 12 in a hospital in Cagnes-sur-Mer, France, where he had been traveling with his wife along the Mediterranean.

Dr. Edmund H. Sonnenblick, a cardiologist whose research formed a basis for the modern treatment of heart failure, which has extended the lives of millions of people, died Saturday at his home in Darien, Conn. He was 74.

Certain diabetes drugs should be used with caution in people who have heart disease or a history of heart failure, researchers from the Lahey Clinic report after analyzing previous studies, a finding they hope will clarify the debate on treatment.

Dr. Richard W. Nesto and his colleagues reviewed the results of seven randomized clinical trials that enrolled a total of 20,000 patients to study Actos and Avandia, two drugs from the class called thiazolidinediones, or TZDs, that lower blood sugar. Their article in tomorrow’s Lancet concludes that while TZDs do increase by 72 percent the relative risk of heart failure in people who have type 2 diabetes or are close to it, the drugs do not raise the risk of cardiovascular death. The risk of heart failure was already known.

"I view this as helpful information because if doctors want to use this drug even despite the recent debate about it, they can more appropriately select patients for the drugs in whom the risk of heart failure would be very, very low," Nesto, who is Lahey’s chair of cardiovascular medicine, said in an interview.

The Lahey report follows another review article by Dr. Steven E. Nissen of the Cleveland Clinic published in June in the New England Journal of Medicine. That analysis found a significant increase in the risk of heart attack for people taking Avandia and a borderline-significant risk of cardiovascular death. The US Food and Drug Administration added a warning to the label for Avandia in August.

Nesto said the data his group examined were more robust than the results Nissen analyzed. A panel of experts judged whether heart attacks occurred in the studies Nesto chose, and all the studies had been previously published.

"We did not find an increase in cardiovascular death despite the increased risk of heart failure and despite the findings of the other meta-analysis that there was a trend toward an increase in the risk of death," Nesto said. "I'm hopeful that this information will help clinicians if they want to use TZDs to more carefully select appropriate patients."

The drugs are still effective at lowering blood sugar, he said. Older drugs that reduce blood sugar have not raised the same degree of concern about cardiovascular side effects, but "these other drugs have not come under the degree of scrutiny that TZDs have," he said.

In a comment that appears in the Lancet, Dr. John G.F. Cleland and Stephen L. Atkin of the University of Hull in England criticize the use of blood sugar levels as a surrogate marker for how well drugs work, rather than patient outcomes such as quality of life and survival.

"All the meta-analyses consistently fail to spot the elephant in the room," they write. "Treatments should be effective rather than merely innocuous."

In a second comment, Dr. Victor Montori of the Mayo Clinic says using surrogate markers represent a false economy in drug testing.

“Patients and society may end up paying dearly for drugs that cause more harm than good,” he writes.

An editorial urges drug makers to do post-marketing studies on the long-term effects of drugs.

“Regulatory agencies must hold manufacturers’ feet to the fire to ensure that these are performed,” it says. “Unless limitations on the understanding, analysis, and communication of drug safety issues are addressed, the TZDs will simply become the latest in a series of preventable drug disasters.”

Nesto said he had not read the comments or the editorial.

“The fact remains that the target of treatment in diabetes patients is still the control of blood sugar,” he said.

Researchers from Boston and Cambridge have won two of three prizes for young cancer investigators.

Angelika Amon (left) of MIT and Dr. Todd R. Golub of Dana-Farber Cancer Institute and the Broad Institute of Harvard and MIT will receive the 2007 Paul Marks Prize for Cancer Research from Memorial Sloan-Kettering Cancer Center. The prize recognizes contributions to understanding the treatment of cancer made by scientists under the age of 45.

Amon studies how chromosomes segregate during cell division and Golub uses genomic approaches to classify subtypes of cancer. They will share a $150,000 prize with the third winner, Gregory J. Hannon of Cold Spring Harbor Laboratory, who studies the biology and biochemistry of RNA interference. All three winners are also Howard Hughes Medical Institute investigators.

As we learn how to perform the neurological exam, a string of prominent lecturers stand before us and offer us the versions of these techniques that they swear by. To test peripheral vision, one neurologist always asks his patients to point to his wiggling fingers, while another flashes numbers, and so on.

We’ve been practicing elements of the exam on our classmates for a few weeks now, but last week was our first chance to test our skills on actual patients.

My charge at Massachusetts General Hospital, Mr. B, had wisps of white hair and a permanently flexed hand that made him look much older than his 52 years. A stroke had paralyzed his right side and he now lived alone with occasional visits from a nurse. Mr. B was gracious though confused, and eager to chat.

I began the exam, shining a light into his eyes while taking quick glances back at my notes. I wiggled my fingers to test his peripheral vision and made him say ahhhh, marveling at the deviated “punching bag” at the back of his throat that signaled damage in a particular nerve. But he tired quickly, I felt badly about making him uncomfortable, and after a series of botched attempts to test my increasingly alarmed patient's hearing with a tuning fork, I found myself rushing through the rest of the exam. Near the end of the allotted time, I decided that my second attempt to take his blood pressure would be my last.

In the debriefing session that followed, I presented the patient’s history and my exam findings to the group: "Mr. B is a 52-year-old former smoker with chronic obstructive pulmonary disease. ..." I followed the blood pressure with the caution that it was "not well heard" -- my stab at medicalese to mean "wow, I can’t believe I literally picked these two numbers at random."

My preceptor was quick to reassure me that physical exams are inherently subjective. One man’s dilated pupil is another man’s constricted one. Our job, she said, was to state our findings as we saw them, with little apology, and to leave room for alternative interpretations.

It was, in large part, kindness that prompted my preceptor’s gross understatement. But I realized that while I fumble my way towards acquiring a standard set of skills, I’m also starting to figure out my doctoring style, pieced together from trial, error, and the wisdom of my instructors. For the first time in my training, I can make my own choice to wiggle if I want to. As for the random-number-generator method for taking blood pressure? -- not so much my style.

A mercury-based preservative once used in many vaccines does not raise the risk of neurological problems in children, concludes a large federal study that researchers say should reassure parents about the safety of shots their children received a decade or more ago. The study, however, did not examine autism - the developmental disorder that some critics blame on vaccines. A separate study due out in a year will look at that issue.

The amount of "good cholesterol" in the blood remains an important marker for heart disease regardless of how much "bad cholesterol" is lowered, researchers said yesterday.

A bill that would reconfigure the leadership of the Department of Social Services was criticized yesterday by union officials, who said the focus of improving child-protection efforts should be at the ground level, where they said social worker caseloads need to be reduced.

Genzyme Corp. of Cambridge and German partner Bayer Schering Pharma AG said they have begun phase 3 trials of their cancer drug Campath to treat multiple sclerosis.

A very early test of an experimental drug seemed to slow the spread of advanced melanoma in a small study, Synta Pharmaceuticals Corp. of Lexington reported in preliminary findings yesterday.

Dr. Gherardo "Zeke" Gherardi (left) of Wellesley, who taught pathology at Tufts Medical School, Boston-Bouve School of Physical Therapy at Northeastern and Boston University School of Medicine and was an associate pathologist at Framingham Union Hospital, died Sept. 6 in an automobile accident near Hearne, Texas, while visiting. He was 86.

It was more than 30 years ago, but Dr. Katharine Treadway (left) vividly remembers answering her first "code" call to revive a hospital patient.

The resuscitation attempt failed, and in this week’s New England Journal of Medicine she recalls what it felt like, as a freshly minted intern, to simply walk away from a life that had just ended.

“Someone had just died. But we all behaved as though that was not at all what had happened,” she writes. “We learned to bury our fear of death in an avalanche of knowledge. … And for good reason. We could not do what we do – take responsibility for the lives of our patients – if we were aware, minute to minute, of the true significance of what we were actually doing.”

The journal is publishing Treadway's essay to spark an online discussion, which the Boston-based publication calls Perspective Forum. Its physician readers are invited to write about how they cope with the emotions they put away while meeting clinical challenges.

Treadway, a Harvard Medical School faculty member and primary care doctor at Massachusetts General Hospital, writes that many doctors have private rituals they observe whenever a patient dies -- she says aloud, "May choirs of angels greet thee at they coming" -- but they rarely share them.

White Coat Notes asked Treadway what she would like to hear from readers, why she chose this topic, and what she teaches medical students about it.

What do you hope to hear in the forum?
What I hope is people will in fact share some of their experiences and write what it was like to be at a code the first time, or other experiences. I hope doing that is just the beginning of 'well, gee, if I write into the New England Journal, maybe I can talk to the doctor I share an office with.' I really believe that we’re all hungry for this.

What do you teach medical students about emotions?
I try to get them to recognize early how powerful they will become in the lives of their patients. I don't mean this in a hierarchical way. I mean when someone is ill, the emotional need that is there is so profound, if they don't recognize how powerful they are, they won't know how to use this in a positive fashion.

What about situations like the code call?
When you focus so intently on the problem you are trying to solve, (it’s) easy to forget about the person. I want them to remember to experience the experience and be aware of what’s taking place, not just the task.

There’s this tremendously fine line that we have to walk in terms of dealing with acute life-threatening situations in which you absolutely have to stifle your emotions. You can’t fling your hands into the air and say, 'Oh my god.' That wouldn’t help anyone.

At the same, time, if you completely shut that off, then you lose something.

How do you find that middle ground?
Part of the message I teach is being honest with yourself about what you have done well or not so well, and being aware of your emotions in a way that allows you to continue and come back another time.

How about your own work?
I love being a doctor. To me it's the combination of the intellectual demands and the fascination of how our bodies work, mixed with dealing with people and all of the interactions that take place in this human drama. I still feel like I have to pinch myself to believe I’m doing this, more than 30 years into it.

Being a primary care doctor, I take care of my patients’ children, or their children’s children, or in one case, the great-granddaughter of my original patient. In addition to teaching medical students who are so eager and idealistic, it’s just so renewing. I feel very lucky.

A Harvard medical student and nursing mother won an appeal today in her lawsuit for extra break time to pump breast milk during her doctor-licensing exam. A state appeals court judge ruled that the National Board of Medical Examiners must grant Sophie Currier of Brookline an additional 60 minutes of rest periods on each day of the exam, which Currier must pass to graduate and begin her residency at Massachusetts General Hospital.

Currier sued the board September 6, arguing that it violated her constitutional rights by denying her more than the 45 minutes of rest periods allotted to all test takers. She also accused the board of gender discrimination.

Last week, a state superior court judge denied her claim, saying Currier could still find a way to expel her milk during the test or on regularly scheduled breaks.

But Appeals Court Judge Gary Katzmann overturned that decision. “In order to put the petitioner on equal footing as the male and non-lactating female examinees, she must be provided with sufficient time to pump breast milk and to address the same physiological and other functions to which those examinees are able to attend,” he wrote.

Currier, who has a 4-month-old daughter, originally planned to take the exam this week, but postponed it until October 4 in hopes of winning her appeal. She already has received permission from the board to take the test over two days instead of one, because she has dyslexia and attention deficit hyperactivity disorder. The board also offered to allow her to bring a breast pump into the exam room and to provide her with a private room in which to express milk during breaks.

Lactating women can experience pain and risk developing infections of their breasts if they don't express milk at least once every three hours, breastfeeding experts say.

Massachusetts General Hospital has landed on two lists of best places to work.

One is the Working Mother magazine's 100 Best Companies, which considers compensation, child-care and flexibility programs, and leave policies. Harvard University also made the non-ranked list, along with Arnold Worldwide, The Boston Consulting Group and Massachusetts Mutual Life Insurance.

The other list is AARP's ranking of Best Employers for Workers Over 50, where it came in 10th. No other Massachusetts-based company made the list of 50 workplaces. The AARP considered recruiting practices; opportunities for development; and work options, such as flexible scheduling, job sharing, and phased retirement, in addition to health and retiree benefits.

The House voted yesterday to expand health insurance for children, but the Democrat-led victory may prove short-lived because the margin was too small to override President Bush's promised veto.

Some of the nation's leading healthcare policy specialists, including a former surgeon general, announced yesterday an initiative to pressure presidential candidates to develop strategies to combat chronic diseases as part of their healthcare plans.

Depressed employees worked an average of two more hours a week and were more effective in their jobs when assigned a telephone "care manager" who counseled them on treatments, a study showed.

The Legislature is again considering a bill that would require health providers in Massachusetts to obtain a patient's consent before treating them with reprocessed medical devices and instruments that are designed to be used once.

Boston University today announced that it has landed a prominent Ebola researcher from Germany to help run its high-security research laboratory in the South End, the second major position filled this month at the controversial facility.

Dr. Elke Mühlberger will oversee research examining how viruses spread as well as projects focused on the smallest biological components of germs. Mühlberger will join BU's National Emerging Infectious Diseases Laboratories in March from the University of Marburg in Germany. The centerpiece of the project, which is under construction on Albany Street, is a Biosafety Level-4 lab where scientists will be able to study the world's deadliest germs, including Ebola, anthrax, and plague.

Mülhberger's research on Ebola and another highly lethal germ, Marburg virus, has been published in such prominent research journals as Science and the Journal of Virology.

Earlier this month, BU announced it had appointed another Ebola researcher to the number two position at the lab. Thomas W. Geisbert, who was named associate director, comes to BU from a similar position at the National Institute of Allergy and Infectious Diseases, where he presides over that agency's Biosafety Level-4 lab.

A Boston doctor is fasting for three days as part of a national push to cancel Haiti's debt to the developed world.

Dr. Evan Lyon, a hospitalist at Brigham and Women's Hospital and a researcher in its division of social medicine and healthcare inequalities, has worked in Haiti for the past 10 years through Dr. Paul Farmer's organization, Partners in Health.

Because of his connection to Haiti, Lyon got involved with the Jubilee USA Network, a coalition of 80 religious denominations across the country that wants Congress to cancel the debt of 26 countries and make it easier for other nations to find financial relief.

"Hunger is the most important issue that we see" in Haiti, Lyon said in an interview yesterday, the second day of having only one small meal and water. "It's not uncommon for the people I take care of to come into the clinic not having eaten for one or two days. I chose to take this fast on with the understanding that for me it's a pretty modest thing to do."

Jubilee, which has organized a 40-day fast across the country that began Sept. 6, takes its inspiration from the biblical meaning of a jubilee year. Debts are canceled and slaves are freed every seven years, according to the book of Leviticus. The Jubilee Act is awaiting a hearing before the U.S. House Financial Services Committee, according to the network.

The state is launching a program to help low-income children with autism.

Eighty autistic children under 9 years old who need a high level of care will receive expanded services beginning this fall from the Massachusetts Department of Mental Retardation's Autism Division through MassHealth, the state's Medicaid program.

The three-year, $2 million project will help children and their families in their homes or through community services, Elin Howe, DMR commissioner, said in an interview.

"It's far more intensive in terms of our typical array of family supports and family services," she said. "There is a decided need for very specialized services for people with autism."

Those services could include one-on-one behavioral therapy or help with communication skills, depending what families ask for, Howe said. Families could also get respite care designed for children with autism or modifications to their homes or vehicles.

Amid the promises of robust tax coffers and thousands of new jobs, Governor Deval Patrick and his health secretary acknowledged last week that the administration's bid to bring three casinos to the state comes with a price: addiction. Those concerns are well founded: Research shows that people living within 50 miles of a casino are twice as likely to fall victim to compulsive gambling as those farther away.

When Boston psychiatrist Jonathan Shay (left) wanted to understand the psychological toll of the Vietnam War on the veterans he treated, he turned to the "Iliad" and the "Odyssey." Today, the John D. and Catherine T. MacArthur Foundation will announce that Shay, 65, has been selected as a 2007 MacArthur fellow "for his work in using literary parallels from Homer's 'Iliad' and 'Odyssey' to treat combat trauma suffered by Vietnam veterans."

Ben Affleck is one of about 20 local luminaries, including Mayor Thomas M. Menino and Boston Pops conductor Keith Lockhart, who have volunteered to have their cheeks swabbed for DNA as part of an international effort to better understand ancient human migration.

Bristol-Myers Squibb Co., the pharmaceuticals giant that is building a $750 million biotech manufacturing plant on the site of the former Fort Devens US Army base, yesterday said it will buy Adnexus Therapeutics Inc., a promising Waltham biotechnology company, for $430 million - plus up to $75 million in additional conditional payments - giving Bristol-Myers Squibb its first drug-discovery operations in Massachusetts.

Unless it receives new evidence, Medicare will not reverse its decision to cut reimbursements for best-selling anemia drugs such as Amgen Inc.'s Aranesp.

Adult preventive health exams and women's gynecologic exams are among the most common reasons to see a doctor, but most preventive services other than Pap smears take place outside those visits, according to researchers from the University of Pittsburgh School of Medicine and Harvard Medical School.

"There's clearly a role for the type of preventive services we studied -- cancer screening, cholesterol testing and counseling about quitting smoking, losing weight and exercise," Dr. John Z. Ayanian of Harvard said in an interview. "It's a question of what's the best approach to get those provided."

Looking closely at the exams, the authors found that checkups including gynecological exams accounted for 1 in 12 adult visits to doctors. Annual exams are more common in the Northeast than in the West, according to previous research. Physicians in Boston, for example, are more likely to say they perform the annual exams than their counterparts in San Diego. People with insurance are more likely to go for physicals than people without coverage.

Annual physical exams "fill a very important role in the US healthcare system," but it wouldn't be feasible to recommend that all adults have annual physicals because there aren't enough primary care physicians or gynecologists, said Ayanian, who practices at Brigham and Women's Hospital. People get most of their preventive services when they come for an acute problem or receive care for chronic conditions, according to the authors' analysis of data from national surveys done from 2002 to 2004.

The study may help guide policy about who should be having preventive exams and what they should include, Ayanian said. People's expectations for blood tests or EKGs during checkups may increase healthcare costs without adding value, the authors found.

"We need to be very selective about what tests we recommend on a routine basis and limit them to those that are likely to have value in affecting people's health rather than reflexively ordering tests out of some sense of tradition," he said.

Talking about the healthcare systems in Canada and the United States has always been a case of compare and contrast, and not just for Michael Moore in "Sicko." A study published today on what patients in Ontario thought about where they received urgent care may be relevant to the current Massachusetts debate on allowing walk-in clinics inside retail stores, but with some caveats.

Like its neighbor to the south, Canada is also suffering from a shortage of primary care physicians. But unlike doctors in the United States, some physicians in Ontario are required by their contracts to provide care after hours, usually until 8 p.m. on weekdays and for a half-day on the weekends. The majority of family practice doctors in the province are moving toward that model, study author Michelle Howard of McMaster University in Hamilton, Ontario, said in an interview.

Even so, some patients still go to independent walk-in clinics or hospital emergency departments for urgent care. A study in today's Annals of Family Medicine surveyed them on which kind of care they liked the best.

Seeing or speaking on the telephone with one's own family physician scored the highest, followed by going to the after-hours clinic affiliated with their doctor. Next came the emergency departement and then a health information telephone service staffed by nurses. Walk-in clinics finished last.

"It wasn't surprising that people were more satisfied if they had gone to their own family physician," Howard said. "I think this lends support to the idea that the (after-hours) service is really valued by patients."

The walk-in clinics in the study were standalone venues staffed by doctors, so they are different in two respects from the MinuteClinics that CVS Corp. hopes to set up inside its drug stores with nurse practitioners or physician assistants seeing patients. The Massachusetts Department of Public Health has held two public hearings on proposed rules governing retail clinics and will bring its findings before the Public Health Council in November at the earliest.

Howard said the Canadian survey of 1,342 patients in Thunder Bay, Ontario, was part of a larger study to test the hypothesis that if family physicians are available after hours, people might be less likely to go to a hospital emergency department. That study is not yet complete.

The science of life is undergoing changes so jolting that even its top researchers are feeling something akin to shell-shock. Just four years after scientists finished mapping the human genome - the full sequence of 3 billion DNA "letters" folded within every cell - they find themselves confronted by a biological jungle deeper, denser, and more difficult to penetrate than anyone imagined.

Scientific celebrities like James Watson and Craig Venter are making their genetic information public knowledge. Will you be able to keep yours private?

Even when we each start carrying around our personal genome disks in our pockets, our data will differ from our children's in thousands of ways.

Researchers at Harvard Medical School, led by genetics professor George Church, are mapping the complete genomes of 10 people.

When Levi Garraway (left) heard that his father was dying of prostate cancer, he decided to do something about it. At the time Garraway was writing his PhD dissertation on infectious diseases. Today, he's an associate member of the Broad Institute, a research collaborative dedicated to applying genomics to diseases such as cancer.

Also, does a chemical formed in cooking french fries really cause cancer and if two pennies are not identical, then what about two atoms of hydrogen?

If yesterday's drill, designed by health and postal authorities to measure how swiftly life-saving medications could be delivered if terrorists seeded the air with anthrax, is an accurate reflection, antibiotic pills could be dispatched to 23,000 households in just under six hours - far faster than authorities anticipated.

About 80 relatives of Fernald Development Center residents came to express fear that the state would try to close the center, altering the lives of its 180 residents, despite a federal court ruling last month granting residents the right to stay.

There is no doubt that many psychiatrists believe that antidepressants, particularly SSRIs like Prozac, Paxil, Zoloft, and Celexa, are helpful in treating depression in adults and adolescents, Alison Bass, a former medical writer for the Globe and author of the upcoming book "Side Effects: A Best-selling Drug on Trial," writes on the op-ed page. But, she asks, who stands to benefit from the latest alarm about an apparent upturn in youth suicide rates? These companies have an enormous stake in reversing the current FDA warnings, she writes.

Catch up to these stories that appeared in the Globe over the weekend:

A local cancer charity that has raised more than $1 million for Massachusetts General Hospital by selling memorial bracelets recalled about 200,000 of the beaded accessories yesterday after receiving a report that a 9-month-old boy became ill after ingesting lead when he put one in his mouth.

Massachusetts consumers soon will have access to information long kept confidential by the healthcare industry: The prices individual hospitals are paid by insurers for performing specific procedures - data state officials hope will encourage comparison shopping and reduce medical costs.

After facing a barrage of criticism, the state backed off plans yesterday to require low-income patients to pay the equivalent of a small insurance premium before they get free care at hospitals.

The US Department of Veterans Affairs is considering expanding the Brockton VA medical center by moving some or all of its Bedford-based services to the city.